Minnesota Department of Human Services
Licensing Division
Sample Policies and Forms for Intensive Supports and Services
245D licensed providers may link to the sample policies and forms below and modify them for use in their programs. Providers are
responsible for ensuring any policy and forms they use meet the 245D licensing requirements, including the samples provided. Read
the applicable statute sections or rule parts to ensure you understand the requirements.
Required policies and procedures
Applicable MN statute or rule
Date of last
revision
Required Policies and Procedures
These policies are required at time of application for providers who do not hold a 245B license.
Drug and Alcohol Prohibition Policy (DOCX)
245A.04, subd. 1(c)
Emergency Use of Manual Restraint (EUMR) Not Allowed Policy (DOCX)
245D.06, subd. 1(a); 245D.06,
07/01/2016
subd. 5, 245D.061; and 9544.0070
245D.06, subd. 1(a); 245D.06,
07/01/2016
subd. 5, 245D.061; and 9544.0070
Emergency Use of Manual Restraint (EUMR) Allowed Policy (DOCX)
10/31/2013
Grievance Policy (DOCX)
245D.10, subd. 2
10/31/2013
Maltreatment of Minors Reporting and Internal Review Policy (DOCX)
245A.66 and 626.556
11/30/2014
Service Termination Policy (DOCX)
245D.10, subd. 3
08/01/2015
Temporary Service Suspension Policy (DOCX)
245D.10, subd. 3
08/01/2015
Vulnerable Adults Maltreatment Reporting and Internal Review Policy (PDF)
245A.65, subd. 1(a) and (b) &
626.557, subd. 4a
10/21/2015
Required Policies and Procedures
All policies must be developed by January 1, 2014.
Admission Criteria Policy (DOCX)
245D.11, subd. 4
09/15/2014
Data Privacy Policy (DOCX)
245D.11, subd. 3
10/31/2013
Emergency Response, Reporting and Review Policy (DOCX)
245D.11, subd. 2; 245D.02, subd.
8; 245D.22, subd 4-7
10/31/2013
Health Service Coordination and Care (Residential Programs) Policy (DOCX)
245D.11, subd. 2(2)
10/31/2013
Incident Response, Reporting and Review Policy (DOCX)
245D.11, subd. 2(7); 245D.02,
subd. 11; 245.91, subd. 6;
609.341, subd. 3 and 14
10/31/2013
Safe Medication Assistance and Administration Policy (DOCX)
245D.11, subd. 2(3)
07/01/2015
Safe Transportation Policy (DOCX)
245D.11, subd. 2(4)
10/31/2013
Universal Precautions and Sanitary Practices Policy (DOCX)
245D.11, subd. 2(1)
10/31/2013
Required Policies And Procedures for Community Residential Settings and Day Services Facilities
All policies must be developed by January 1, 2014. Samples will be available in July and August 2014.
Program Abuse Prevention Plan (PAPP) (DOCX)
245A.65, subd. 2 (a) & 245A.65,
subd. 2 (a)
07/01/2015
Documentation Requirements – Optional Program Forms
45 Day Meeting Summary (DOCX)
Updated 07/01/16
09/15/2014
1
Minnesota Department of Human Services
Licensing Division
Admission and Discharge Register Form (DOCX)
10/31/2013
Emergency Report and Internal Review Form (DOCX)
10/31/2013
Fire Drill Log (DOCX)
10/31/2013
Funds and Property Authorization (DOCX)
10/31/2013
Health Needs Change Notice (DOCX)
07/01/2015
Health Needs Record (DOCX)
10/31/2013
Incident Report and Internal Review (DOCX)
10/31/2013
Individual Abuse Prevention Plan (IAPP) Form (DOCX)
245A.65, subd.2(b) & 626.6557,
subd. 14
10/31/2013
HCBS Incident Reporting Requirements - Who to Notify Form (DOCX)
09/15/2014
HCBS Service Recipient Rights Packet (DOCX)
09/15/2014
HCBS Service Recipient Rights Restrictions (DOCX)
10/31/2013
Intensive Support Self-Management Assessment (DOCX)
12/30/2014
Medication Administration and Emergency Medical Authorization (DOCX)
07/01/2015
Medication Administration Review Record (DOCX)
10/31/2013
Medication and Treatment Administration Packet (DOCX)
10/31/2013
Medication Setup Record (DOCX)
10/31/2013
Notice of Service Termination (DOCX)
08/01/2015
Notice of Temporary Service Suspension (DOCX)
08/01/2015
Person-Centered Planning and Service Delivery Requirements (DOCX)
10/31/2013
Progress Review Report for Intensive Support Services (DOCX)
07/01/2015
Psychotropic Medication Use and Monitoring Record (DOCX)
10/31/2013
Quality Management Evaluation and Program Improvement Plan (DOCX)
10/31/2013
Release of Information Authorization (DOCX)
10/31/2013
Satisfaction Evaluation (DOCX)
10/31/2013
Service Admission Checklist for Intensive Services (DOCX)
09/15/2014
Service Recipient Information Cover Sheet (DOCX)
09/10/2015
Service Recipient Record Checklist (DOCX)
10/31/2013
Staff Annual Training Record (DOCX)
07/01/2016
Staff Orientation Record (DOCX)
07/01/2015
Progress Review Meeting Summary (DOCX)
07/01/2015
Supports and Outcome Methods for Intensive Support Services (DOCX)
10/31/2013
245A.04, subd. (9)
Variance Request (PDF)
Updated 07/01/16
2
04/16